If two descents are visible in the jugular venous pulse for each cardiac cycle, it is usually a result of the X and the y descents unless the x descent is far separated from the X descent as with long PR intervals. The wave preceding the X descent is the a wave during sinus rhythm, and the wave preceding the y descent is the v wave. In cases where double descents (X and y) are noted, the relative dominance of the X vs y (systolic vs diastolic descent) will easily help in identifying the flow...

Tricuspid regurgitation can arise from an anatomical and or functional defect of any of the components of its complex anatomy. The etiological factors may be congenital or acquired. The pathological process can be genetic, inflammatory, infective, traumatic, degenerative, or neoplastic. Sometimes more than one component ofthe valve structures may be involved (88,89). The annulus may become idiopathically dilated or calcified and therefore may not function normally. Dilated annulus with...

Because the normal pulmonary pressures are low, there is no audible or recordable normal pulmonary ejection sound. Therefore, when a pulmonary ejection sound or click is heard, it is always pathological. Fig.11. Stop frames from two-dimensional echocardiogram taken from a patient with a bicuspid aortic valve and aortic ejection click. The short axis shows the two cusps(A) in the closed position and (B) in the open position. The aortic valve cusps are seen to be slightly domed in systole...

A schema for the differential diagnosis and the significance of the double descents is shown in Table 3, both in the presence and the absence of pulmonary hypertension. Differential Diagnosis of Double Descents in Jugular Venous Pulse In pulmonary hypertension In the absence of pulmonary hypertension x'&gt y Indicates good right ventricular (RV) function Compensated RV function Normal young adult Extra source of venous return, e.g., ASD x' y Increased v wave pressure with NO restriction to...

Ductus arteriosus is a vascular channel that is normally present in the fetus connecting the aorta just distal to the left subclavian artery to the pulmonary trunk near the origin of the left pulmonary artery. In the unaerated lungs of the fetus, the pulmonary capillaries are shut down. The pulmonary vascular resistance is equal to the systemic resistance. The mixed venous and placental blood from the right ventricle passes through the ductus into the descending aorta. At the same time, part of...

In view of the above observations, one can easily state that a split S2 at the apex is abnormal (Figs. 23B,C) and should make one consider the following possibilities 1. P2 is loud and may indicate the presence of pulmonary hypertension. 2. If the P2 is not loud and there is no evidence of pulmonary hypertension, the right ventricle may be enlarged, as in volume overload, and one should consider lesions such as an atrial septal defect. 3. P2 is normal and probably audible at apex because of a...

The normal A2 is heard over a sash area extending from the second right intercostal space to the apex area. The normal P2 is heard over the second and third left intercostal space. Thus, a normal split ofthe S2 is best heard over the second or third left intercostal space, where both components are audible. Asking the patient to take a breath in may bring in too much noise caused by the breath sounds. This may actually interfere with the assessment of the split, whether present or not, and, if...

Inspection of the head and or hands (8) is often useful in detecting congenital disorders associated with underlying heart disease. In this section I will mention the Down, Leopard, Noonan, Williams', Osler-Weber-Rendu, and Holt-Oram syndromes, as well as tuberous sclerosis and cyanotic congenital heart disease. The importance of clubbing will be discussed under the latter heading. Down syndrome occurs in 1 of 1000 newborns and is characterized by a vacant expression on the face, mental...

This complication used to occur before the thrombolytic era in approx 1-2 of patients with myocardial infarction. In the current era of routine thrombolytic therapy, its frequency has fallen to about 0.2 (107). It accounts for about 5 of all deaths from myocardial infarction. The septal rupture is usually associated with the first myocardial infarction and will generally occur within the first week after the infarct. It is more common with anterior myocardial infarction than with inferior...

Diseases of Connective Tissue and Joints A good deal of information about cardiovascular diseases can be obtained by the thorough inspection of a patient using only the unaided senses. Inspection is a frequently overlooked aspect of cardiovascular physical diagnosis. This chapter discusses the recognition of the local and systemic manifestations of cardiovascular disease under the following headings general observations, congenital syndromes, vascular diseases, valvular heart disease, endocrine...

The normal apical impulse has a single outward movement, which is palpable. The rise in left ventricular wall tension during the end of diastole caused by atrial contraction, which may be recorded even in the normal subjects by sensitive instruments (A wave in the apexcardiogram), is not palpable (Fig. 7A). However, in patients with decreased ventricular compliance (stiff ventricles, which offer resistance to expansion in diastole), the atrium compensates for this by generating a stronger or...

Mitral regurgitation, therefore, can arise from anatomical and or functional defect from any one ofthe components of its complex anatomy (48). The lesion may result from a congenital or an acquired cause. The process may be genetic, inflammatory, infective, traumatic, ischemic, degenerative, or neoplastic in nature. As often is the case, more than one component of the structures may be involved. Rarely, mitral regurgitation may also be induced iatrogenically during surgical commissurotomy or...

Significant and longstanding hypertension, whether secondary or primary, can lead to cardiac pathological changes and give rise to signs and symptoms. The sequence of these changes pertaining to the heart will be reviewed without attempting to review all of the vascular changes that lead to eventual target-organ damage in other parts of the body, including the brain and the kidney. Hypertension, the essential or the primary type, is a fairly common disorder. The disorder is characterized by a...

This is the major fall in atrial pressure in systole and is caused by RV contraction pulling on the closed tricuspid valve and ring (26,40). Fig. 12. Jugular venous pulse (JVP) and jugular venous flow (JVF) velocity recordings from a patient with pulmonary hypertension in a decompensated state. Note the more prominent y descent compared to the x' descent in the JVP. It corresponds to the dominant diastolic flow (Df) compared to the systolic flow (Sf). The added diagrams of the heart help...

S3 is a sound that occurs at the end of the rapid filling phase of diastole at pressures that are generally low. Therefore, the S3 is a low-frequency sound or a thud similar to the sound caused by a small lead ball falling on a cushioned floor. It occurs at the peak of the rapid filling phase and is therefore separated from the S2 by the combined duration of the isovolumic relaxation and the period of rapid inflow. The former is approximately between 60 and 100 ms. The latter lasts an average...

In the clinical assessment of the arterial pulse, it is worth remembering the 1. The three features of the arterial pulse that should be diligently sought for are the amplitude, the upstroke, and the pulse contour abnormalities. 2. Other features include the determination of rate, rhythm, pulse deficit, symmetry, radio-femoral delay, bruits, and specifically looking for the peripheral signs of aortic regurgitation when indicated. 3. Palpation of the carotid arterial pulsation is necessary to...

Dilated cardiomyopathy refers to intrinsic myocardial disease. The etiology is often idiopathic, while in others it may be related to definable etiological factors such as ethanol-related myocardial damage or a definite viral myocarditis. Whatever may be the etiology, the hallmark of the disorder is a dilated poorly contracting left ventricle, and Pathophysiological changes Clinical symptoms signs Pathophysiological changes Clinical symptoms signs Severe hypertension or decreased LV systolic...

In most patients who have undergone cardiopulmonary bypass, the altered flow velocity patterns are not associated with alterations in right heart pressures. Postoperatively, the right atrium seems to behave as a conduit rather than a capacitance chamber. Its capacitance function may be attenuated initially because of edema and later probably due to stiffness caused by scarring. The loss of buffering function of the atrium as a capacitance chamber leads to full reflection of the diastolic flow...

Tricuspid Regurgitation Secondary to Pulmonary Hypertension From the foregoing consideration, it will be apparent that tricuspid regurgitation may occur with either normal right ventricular systolic pressures or elevated right ventricular systolic pressures. Chronic pulmonary hypertension, regardless of etiology, will have an element of reactive vasospasm initially in the pulmonary arterial bed. With persistence of high pressures, intimal damage will ensue and lead to obstructive changes...

Mitral regurgitation is a volume overload state for the left ventricle because during diastole the ventricle receives not only the normal pulmonary venous return, but also the extra volume of blood, which goes into the left atrium during systole. The left ventricle thus has two outlets for systolic emptying in mitral regurgitation, namely, the aorta and the left atrium. The volume overload would result in left ventricular dilatation and enlargement. The left ventricular dilatation is...

As opposed to the early rapid filling phase of diastole, the period of slow filling or diastasis and the atrial contraction phase are influenced by compliance, which is mainly secondary to the passive elastic properties ofthe myocardium (Fig. 30). Compliance can be expressed for the whole ventricle in terms of volume-pressure relationship (dV dP) or the converse, expressing it as unit pressure change for unit increase in volume (dP dV). The latter is termed chamber stiffness. When the same is...

Step 1 Detection of the Physical Signs Is the patient excessively tall or short Body build should be noted. Is the patient alert or somnolent Are there any abnormalities in the gait Note the clothing for evidence of weight change or tobacco use. Are there any facial features to suggest a collagen or endocrine disorder such as butterfly eruption or exophthalmos, respectively A mask-like face may suggest parkinsonism, scleroderma, or myotonia dystrophica, whereas a vacant expression suggests Down...

Laplace's Law defines the relationship between the wall tension (T) and the pressure (P) and the radius (r) for a thin-walled cylindrical shell (Fig. 15). The tension is directly related to the pressure and the radius. If the wall has a thickness, then the circumferential wall stress is given by Lame's equation (Fig. 15), where the wall tension (T) is related to the pressure (P) and the radius (r) and inversely related to the wall thickness (h). In other words, hypertrophy of the wall is a...

The character of the apex beat is assessed in terms of its dynamicity duration, and whether the impulse is single, double, or triple. If the apical impulse cannot be felt or seen, it stands to reason that one cannot assess its character. This may be because of both cardiac and extracardiac factors. In fact, in patients with thick chest walls, obese patients, and patients with chronic obstructive pulmonary disease where one does not expect to be able to feel the apical impulse, mere palpability...

The atrium normally contracts at the end of diastole and gives an extra stretch to the ventricles. When the ventricular compliance is significantly reduced because of factors such as hypertrophy, ischemia, infarction, fibrosis, or infiltrates, then this evokes a more vigorous contraction from the atrium. This augments ventricular filling at the end of diastole and helps in its expansion (88). The increased force of atrial contraction also raises the atrial a wave pressure peak. This augmented...

The side effects of nifedipine include postural hypotension, pedal edema, and gum hyperplasia. Pedal edema may occur with higher doses (&gt 60 mg d) in 5-10 of cases (122). Gum hyperplasia may occur in 38 of patients who have been on nifedipine for 3 mo or more (123). Patients with poor dental hygiene are more liable to have gum hyperplasia. Dilantin and cyclosporine are other drugs that may give rise to gum hyperplasia (124). Angiotensin-Converting Enzyme Inhibitors These drugs produce rapid...

Next we shall consider the jugular venous flow events as related to the jugular venous pulse contours. Although the jugular venous column is in direct continuity with the right atrium, the venous system is innervated by the sympathetic system, which can influence the tone of the smooth muscles in their walls (19) and as such affect the level to which the column will rise for any given volume status ofthe individual and the corresponding right atrial pressure. With that background we shall...

The causes of a delayed P2 component can also be approached using the same three categories as mentioned for delayed A2. The right bundle branch is a long thin fascicle running under the endocardium on the right ventricular side ofthe interventricular septum. It crosses the right ventricular cavity through the muscle bundle called the moderator band and arborizes as a Purkinje network at the base of the anterior right ventricular papillary muscle. The conduction through the right bundle can be...

Elevated venous pressure with the sharpy descent and deep y trough' in constrictive pericarditis has been known as the diastolic collapse of Friedreich for more than a century (20). However, atypical cases, some with rapidly evolving constrictive pericarditis, have been described, which show only a dominant x' descent despite high venous pressure (16,53). As expected in these patients, the RV early diastolic pressure was quite high, with very little pressure difference between the right atrium...

Coronary artery disease may be suspected if any ofthe cardiac risk factors are present (hypertension, hyperlipidemia, smoking, diabetes, obesity) or in the presence of a diagonal ear crease sign, prior mediastinal radiation, progeria, polycythemia, Tangier disease, or in a cocaine user. Hypertension may be detected by a funduscopic examination. Hypertensive retinopathy is graded by the Keith-Wagner-Barker criteria (51) Grade 1 There is generalized narrowing of the arterioles, with the A-V ratio...

In acute rheumatic fever the inflammatory process may affect the leaflets or the chordae and the valve may become incompetent with somewhat rolled-up edges of the leaflets without any significant stenosis. With chronic rheumatic involvement, the mitral valve becomes predominantly stenotic because ofcommissural fusion. When the leaflets are significantly tethered and in particular contracted, mitral regurgitation could result. The pathological changes will often be such that the orifice is not...

The time of occurrence ofthe individual components A2 and P2 may be delayed ifthe duration of systole is lengthened either because of electrical or mechanical delays or if the onset of flow reversal in the aortic root or the pulmonary artery is delayed because of changes in impedance to forward flow (4,32-36) . When there is an electrical conduction defect such as a bundle branch block, the affected side will lengthen the electrical portion ofthe duration ofthe electromechanical systole. This...

A careful examination of the face will detect patients with acromegaly, thyroid disease, Cushing's disease, amyloidosis, gout, and ochronosis. Acromegaly is detected by looking at the head and the hands. These patients have a lantern jaw, coarsening of the facial features (best determined by comparing old photographs), widely spaced teeth, macroglossia, and spade-shaped hands (Fig. 8) Acromegaly is associated with hypertension of the low-renin type (89). There is an increased incidence of...

A split S2 that is audible on expiration is often a clue to some abnormality ofthe timing of the individual A2 and P2 components (Fig. 23A). It may indicate one of three possibilities 1. Relatively wide physiological split of S2 with normal sequence and one must consider the causes of a delayed P2. 2. Reverse or paradoxical split of S2 and abnormal P2-A2 sequence and one must consider the causes of a delayed A2. 3. Relatively fixed split of S2 as in atrial septal defect. In the normal adult,...

Simple bedside maneuvers applied in appropriate situations can be quite useful in sorting out lesions in which the distinction is not clearly apparent. Again, understanding the physiological changes induced by the maneuvers is a preliminary step in understanding their likely effects on a given clinical lesion. Under this heading we will discuss the effect of respiration, the application of the Valsalva maneuver, the effect of changes in postures such as standing and squatting, and finally the...

The heart during systole, becoming smaller, generally withdraws from the chest wall except for the apex for the reasons explained above. The effect of this withdrawal on the chest wall can be observed as an inward movement of the chest wall during systole called retraction. Although the heart is basically comprised of two separate pumps (right and left ventricles), these two pumps operate normally at two vastly different pressures. Left ventricular systolic pressures being approximately five...